page 1 of 3
NPPSA 2/08 – USLI
CARRIER:
Nonprofit Premises Preferred Product
NONPROFIT PREMISES PREFERRED PRODUCT SUPPLEMENTAL APPLICATION
All questions must be answered and application must be signed by applicant.
Please submit with a completed Acord 125 Application.
SECTION I. GENERAL INFORMATION:
1. Name of organization:
2. Mailing address:
Zip code:
3. Location address (if different than above):
Zip code:
4. Description of operation/services offered:
5. Web site address:
6. E-mail address:
7. Does the organization have tax exempt status as defined by the I.R.S.?
q Yes q No
SECTION II. PREMISE PREFERRED:
8. Are revenues greater than $10,000,000?
q Yes q No
9. Please provide the square footage of the applicant’s premises:
10. Does the applicant have an international exposure?
q Yes q No
If “Yes,” please provide details:
11. Does the applicant have any of the following exposures?
q Yes q No
q Gymnasium q Swimming pool q Soup kitchen q Adoption q Childcare q Habitational q Play center
q Food bank q Abortion clinic q Thrift store
12. Does the applicant have a stable or farm exposure?
q Yes q No
13. Does applicant provide Web and/or software development or programming services?
q Yes q No
14. Are there functioning smoke detectors on the premises?
q Yes q No
15. Does the risk contain aluminum wiring?
q Yes q No
16. Does the risk have 100% of the wiring on functioning circuit breakers?
q Yes q No
Important Note: Coverage is limited to premises liability at the location address(es) scheduled in our policy, subject to the terms and conditions
of our policy. The products-completed operations hazard is not insured.
SECTION III. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY (if eligible):
17. Is the organization involved in product research, development, testing and/or certification?
q Yes q No
18. Does the organization engage in any disciplinary actions as a result of peer review activities?
q Yes q No
19. Does the organization administer or sponsor any insurance programs?
q Yes q No
20. Is the organization involved in any accreditation or standard setting activities?
q Yes q No
21. Is the organization involved in any labor/union negotiations or collective bargaining activities?
q Yes q No
22. Total number of employees: Full time:
Part time:
Volunteers:
Seasonal:
23. Number of members:
Number of chapters:
If there are chapters, is coverage requested for them under this policy?
q Yes q No
24. Does the applicant have any subsidiaries requiring coverage?
q Yes q No
If “Yes,” please complete the Nonprofit Subsidiary Addendum (NPSADD).
25. Name and title of individual designated to receive all notices on behalf of the insured:
Title:
Phone number:
page 2 of 3
NPPSA 2/08 – USLI
26. Directors and officers liability insurance carried:
Insurer
Limits of liability
Premium
Retention
Policy Period
27. Does the organization currently carry general liability insurance?
q Yes q No
28. Please provide the following financial information for the last three years. (If organization in existence less than three years please provide
budgeted revenue/expense statement for next three years).
Year
Total Revenues
Net Income (Loss)
Current Fund Balance*
$
$
$
$
$
$
*Fund balance = Total Assets - Total Liabilities
29. Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to,
Equal Employment Opportunity Commission, State Human Rights Boards, Municipal, State or Federal Regulatory Authorities),
against the organization or any person proposed for insurance in the capacity of director, officer, trustee, employee or
volunteer of the organization? (If “Yes,” please forward a completed USLI supplemental claims application.)
q Yes q No
30. Is any person proposed for this insurance aware of any fact, circumstance or situation, which may result in a claim
against the organization or any of its directors, trustees, officers, employees or volunteers? (If “Yes,” please forward
a completed USLI supplemental claims application.)
q Yes q No
SECTION IV. FIDUCIARY LIABILITY (AVAILABLE FOR 100 EMPLOYEES OR LESS):(If “No,” fiduciary will not be offered.)
31. Does each pension plan use an outside investment manager?
q Yes q No
32. Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of
1982, as amended (the “Code”) including eligibility, participation, vesting, fiduciary responsibility and funding standards?
If “No,” please attach details.
q Yes q No
33. In the past two years has there been or is there now under consideration any material changes to a plan or
termination/consolidation of a plan? If “Yes,” please attach details.
q Yes q No
34. Has there been or is there now pending any claims(s) against any proposed insured arising out of any plan?
If “Yes,” please attach details.q Yes q No
35. Does any proposed insured have knowledge or information of any act, error or omission which might give rise to a
claim under the proposed fiduciary liability coverage? If “Yes,” please attach details.
q Yes q No
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
California: For your protection California law requires the following to appear on this application. Fraud Statement: Any person who knowingly presents false or
fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that
it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral,
or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows
to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and
confinement in prison.
Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, fines or a denial of insurance benefits
Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
page 3 of 3
NPPSA 2/08 – USLI
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds
of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky and Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee, Virginia and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
STATE NOTICES
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard
assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not
have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application
for the policy or otherwise.
Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to
“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the
company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or
any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance
applications are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL
MISREPRESENTATION OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND
WITHOUT EFFECT OR PROVIDE THE COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or
exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside
the state of Utah, for which coverage is sought under the same policy.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:
License #:
Agent’s signature:
Main agency phone number:
(Required in New Hampshire)
Agency mailing address:
City:
State:
Zip:
The signer of this Application acknowledges and understands that the information provided herein is material to the Company’s acceptance of the risk and
issuance of the requested policy. The signer of this Application represents that the information provided herein is true and correct in all matters. Any changes
in the information represented in this Application occurring prior to the effective date of a policy shall be promptly reported to the Company in which case, the
Company has the right to modify or withdraw any quote or binder issued based on such changes. The Company has the right but not the obligation to investigate
any representation(s) in this Application. A decision by the Company not to investigate shall not estop the Company from relying on this Application in issuing a
policy. It is agreed that this Application and any material submitted therewith, including but not limited to any supplemental Application(s), shall be the basis of
any policy that is issued.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
Applicant’s signature:
Title:
President, Chairperson of the Board, Managing Member, or Executive Director
Date:
page 1 of 1
Privacy Notice 11/21 – USLI
Privacy Notice At Collection
We may need to collect certain personal information to provide you with our services and products. For information
on how we store, use and protect personal information, please see our Privacy Policy accessible on our website,
https://www.usli.com/privacy-policy/.
NPPSA 2/08 – USLI
CARRIER:
Nonprofit Premises Preferred Product
NONPROFIT PREMISES PREFERRED PRODUCT SUPPLEMENTAL APPLICATION
All questions must be answered and application must be signed by applicant.
Please submit with a completed Acord 125 Application.
SECTION I. GENERAL INFORMATION:
1. Name of organization:
2. Mailing address:
Zip code:
3. Location address (if different than above):
Zip code:
4. Description of operation/services offered:
5. Web site address:
6. E-mail address:
7. Does the organization have tax exempt status as defined by the I.R.S.?
q Yes q No
SECTION II. PREMISE PREFERRED:
8. Are revenues greater than $10,000,000?
q Yes q No
9. Please provide the square footage of the applicant’s premises:
10. Does the applicant have an international exposure?
q Yes q No
If “Yes,” please provide details:
11. Does the applicant have any of the following exposures?
q Yes q No
q Gymnasium q Swimming pool q Soup kitchen q Adoption q Childcare q Habitational q Play center
q Food bank q Abortion clinic q Thrift store
12. Does the applicant have a stable or farm exposure?
q Yes q No
13. Does applicant provide Web and/or software development or programming services?
q Yes q No
14. Are there functioning smoke detectors on the premises?
q Yes q No
15. Does the risk contain aluminum wiring?
q Yes q No
16. Does the risk have 100% of the wiring on functioning circuit breakers?
q Yes q No
Important Note: Coverage is limited to premises liability at the location address(es) scheduled in our policy, subject to the terms and conditions
of our policy. The products-completed operations hazard is not insured.
SECTION III. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY (if eligible):
17. Is the organization involved in product research, development, testing and/or certification?
q Yes q No
18. Does the organization engage in any disciplinary actions as a result of peer review activities?
q Yes q No
19. Does the organization administer or sponsor any insurance programs?
q Yes q No
20. Is the organization involved in any accreditation or standard setting activities?
q Yes q No
21. Is the organization involved in any labor/union negotiations or collective bargaining activities?
q Yes q No
22. Total number of employees: Full time:
Part time:
Volunteers:
Seasonal:
23. Number of members:
Number of chapters:
If there are chapters, is coverage requested for them under this policy?
q Yes q No
24. Does the applicant have any subsidiaries requiring coverage?
q Yes q No
If “Yes,” please complete the Nonprofit Subsidiary Addendum (NPSADD).
25. Name and title of individual designated to receive all notices on behalf of the insured:
Title:
Phone number:
page 2 of 3
NPPSA 2/08 – USLI
26. Directors and officers liability insurance carried:
Insurer
Limits of liability
Premium
Retention
Policy Period
27. Does the organization currently carry general liability insurance?
q Yes q No
28. Please provide the following financial information for the last three years. (If organization in existence less than three years please provide
budgeted revenue/expense statement for next three years).
Year
Total Revenues
Net Income (Loss)
Current Fund Balance*
$
$
$
$
$
$
*Fund balance = Total Assets - Total Liabilities
29. Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to,
Equal Employment Opportunity Commission, State Human Rights Boards, Municipal, State or Federal Regulatory Authorities),
against the organization or any person proposed for insurance in the capacity of director, officer, trustee, employee or
volunteer of the organization? (If “Yes,” please forward a completed USLI supplemental claims application.)
q Yes q No
30. Is any person proposed for this insurance aware of any fact, circumstance or situation, which may result in a claim
against the organization or any of its directors, trustees, officers, employees or volunteers? (If “Yes,” please forward
a completed USLI supplemental claims application.)
q Yes q No
SECTION IV. FIDUCIARY LIABILITY (AVAILABLE FOR 100 EMPLOYEES OR LESS):(If “No,” fiduciary will not be offered.)
31. Does each pension plan use an outside investment manager?
q Yes q No
32. Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of
1982, as amended (the “Code”) including eligibility, participation, vesting, fiduciary responsibility and funding standards?
If “No,” please attach details.
q Yes q No
33. In the past two years has there been or is there now under consideration any material changes to a plan or
termination/consolidation of a plan? If “Yes,” please attach details.
q Yes q No
34. Has there been or is there now pending any claims(s) against any proposed insured arising out of any plan?
If “Yes,” please attach details.q Yes q No
35. Does any proposed insured have knowledge or information of any act, error or omission which might give rise to a
claim under the proposed fiduciary liability coverage? If “Yes,” please attach details.
q Yes q No
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
California: For your protection California law requires the following to appear on this application. Fraud Statement: Any person who knowingly presents false or
fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that
it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral,
or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows
to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and
confinement in prison.
Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, fines or a denial of insurance benefits
Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
page 3 of 3
NPPSA 2/08 – USLI
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds
of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky and Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee, Virginia and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
STATE NOTICES
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard
assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not
have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application
for the policy or otherwise.
Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to
“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the
company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or
any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance
applications are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL
MISREPRESENTATION OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND
WITHOUT EFFECT OR PROVIDE THE COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or
exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside
the state of Utah, for which coverage is sought under the same policy.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:
License #:
Agent’s signature:
Main agency phone number:
(Required in New Hampshire)
Agency mailing address:
City:
State:
Zip:
The signer of this Application acknowledges and understands that the information provided herein is material to the Company’s acceptance of the risk and
issuance of the requested policy. The signer of this Application represents that the information provided herein is true and correct in all matters. Any changes
in the information represented in this Application occurring prior to the effective date of a policy shall be promptly reported to the Company in which case, the
Company has the right to modify or withdraw any quote or binder issued based on such changes. The Company has the right but not the obligation to investigate
any representation(s) in this Application. A decision by the Company not to investigate shall not estop the Company from relying on this Application in issuing a
policy. It is agreed that this Application and any material submitted therewith, including but not limited to any supplemental Application(s), shall be the basis of
any policy that is issued.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
Applicant’s signature:
Title:
President, Chairperson of the Board, Managing Member, or Executive Director
Date:
page 1 of 1
Privacy Notice 11/21 – USLI
Privacy Notice At Collection
We may need to collect certain personal information to provide you with our services and products. For information
on how we store, use and protect personal information, please see our Privacy Policy accessible on our website,
https://www.usli.com/privacy-policy/.